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Module: Promoting Sexual Health

How effective is sexual health promotion among men who have sex with
men (MSM) in the UK?
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Men who have sex with men (MSM) is one of the vulnerable groups in
the UK. This group is of great concern because of high rates of STIs and
HIV. The main focus of this essay is to analyse the effectiveness of
strategies to reduce HIV and STIs among MSM. In the beginning of the
essay some of the recent data and statistics of HIV/STIs in the United
Kingdom (UK) will be looked at to find out the epidemiology of
HIV/STIs among MSM in the recent years. Then, the essay will be
elaborated to find out why there has been so much increase in the rate of
HIV and STIs among the group. The essay will be finally concluded by
mentioning what has been done so far to reduce the rate of HIV/STIs in
this particular group and what can be done in future.

MSM experience poor and worsening sexual health in the UK. London
in particular has increase rate of MSM Public Health England (PHE)
(2014). According to data from National Aids Trust (NAT) (2014), in
2013, almost 43,500 MSM with men were living with HIV in the UK, of
whom 18% were unaware of their infection. A big numbers of men who
have sex with men are being diagnosed with HIV each year in the UK
and the number of newly diagnosis has increased from 2,450 in 2004 to
3,250 in 2013. PHE (2014) says MSM represents less than an estimated
2% of the London adult population (3.8% of the male population).
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However, MSM constituted 24% of all London residents diagnosed with

new sexually transmitted infections (STIs) in sexual health clinics in
2013. Furthermore, PHE (2014) confirms that the increase rise of
syphilis and gonorrhoea is particularly high among MSM. Other STIs
are also present among MSM. For example, in 2013, 19% of all cases of
Chlamydia infection diagnosed in London sexual health clinics were in
MSM. Actual numbers of MSM diagnosed with a new STIs in London
sexual health clinics have increased by 15% between 2012 and 2013.

Several risk factors are associated with such high figures of STIs and
HIV in this particular group. One of the risky behaviours that influence
the rise of STIs and HIV among the group of MSM is due to the practice
of unprotected oral and anal intercourse PHE (2014). MSM put
themselves at risk of exposure to HIV through unprotected intercourse
with regular partners and do not look it as a risky behaviour because of
them being the regular partners. The groups of MSM do not know about
the HIV status of either group. They also put at risks by involving
themselves in multiple sexual relationships. It has been found out that a
large numbers of MSM do not know that they are infected with HIV
PHE (2014). Furthermore, NAT (2014) explains that increased number
of diagnoses amongst this group reflects both on-going high levels of
HIV transmission and an increase in HIV testing. The transmission of
these infections indicates high levels of risky sexual behaviour including
multiple sex partners and unprotected anal intercourse (UAI) among
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MSM. Other factors include being involved in drug and alcohol, low
family support and late presentation for HIV testing. And also, this
diverse population continues to experience inequalities in health and
wellbeing and in other areas such as the experience or fear of stigma and
discrimination despite new policies and government laws for this group
PHE 2014a.

When compared with the general population, MSM have worse sexual
health including HIV and sexually transmitted infections (STIs). The use
of illicit drugs among MSM is widespread Bonell et al (2010). It has
been shown that there is a direct correlation between use of illicit drugs
and the involvement of risky sexual behavior Bonell et al (2010).
Furthermore, there is a direct relation between involvement of risky
sexual behavior and the risks of transmission of STIs and HIV. These
particular groups of population are at risk of worse mental health and
wellbeing and are more likely to use alcohol, drugs and tobacco. These
health inequalities with regard to their sexual health and mental health
seem to influence each other PHE 2014a.

Fear of stigma and discrimination from family and friends is a huge

problem faced by the group of MSM. A study done by Dowson et al
(2012) is about fear among MSM regarding the sexual health revealed
that MSM is a minority group who still face less or no acceptance
among family members and friends. MSM fear to open about their
sexual health to friends and family. They have fear about the anxiety
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over the reactions towards them. There is fear of stigma and

discrimination at work place and in public place. MSM worry about the
impact on day to day life including work, insurance and travel if they are
open about their sexual health. There are cases of inequalities in health
and wellbeing in family or in public places PHE 2014a. There is also a
misconception that HIV and STIs are seen as gay disease. People fear
that they will be judged because of their sexual orientation and their
sexual health Bonell et al (2010).

There is a trend of late presentation with HIV infection to the clinics

among some groups in MSM in the UK despite government initiatives to
increase the rate of HIV testing. Fear of death delays the early
presentation in the clinics Dowson et al (2012). By this time, HIV virus
has already mutated and several complications have already occurred.
According to World Health Organisation (WHO) (2014), late diagnosis
of HIV results in a severe prognosis with higher chance of increased risk
of permanent disability. There is likelihood of increase in mortality.
Furthermore, late diagnosis results in ongoing transmission of HIV and
other STIs to sexual partners Medical Diagnosis for HIV and Sexual
Health (MEDFASH) (2013).

There is also misconception that they would have symptoms of HIV.

People wait for specific symptoms of HIV to go for testing. People do
not go for certain symptoms like weight loss and lethargy. They wait for
symptoms of HIV which do not occur until the end. By this time, HIV
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has already turned into AIDS and they are in the later stage of their life.
Some groups of MSM also express bad experiences from healthcare
workers. Dowson et al (2012) found out that there were cases where
MSM were unwilling to do HIV testing because of bad approach from
the healthcare workers. Asking direct question like do you want HIV
testing? in front of public can reduce the likelihood of willingness for
HIV testing.

Promoting effective strategies regarding sexual health is hard to

distribute equally within a diverse group of population in the UK
Department of Health (DOH) (2014). There is a strong correlation
between deprivation and the rate of STIs and HIV among MSM.
Integrated sexual health model is a strategy applied by the DOH to
reduce the occurrence of STIs and HIV among MSM in the UK. This
model works in improving sexual health by providing access to services
through one stop shops. In this one stop shops, public can have access
to most of sexual health needs in one site. There is one health
professional in their services to the public with extended hours and the
locations are easy to access as well DOH (2014).

PHE has set out recommendations to decrease inequalities among MSM

to reduce HIV incidence. For bringing this change, PHE considers the
health and wellbeing of MSM in the areas of Sexual health, mental
health and substance use among younger generation to maintain a
standard of living well and ageing well. This in turn leads MSM to have
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the control and opportunity to make healthy choices as they become

sexually active. They feel respected and valued by the community that
they live in. PHE works to make individual recommendations for MSM
so that these groups become knowledgeable to make healthy choices.
PHE also works to make recommendations for educational facilities,
health care workers and other wider community who are directly or
indirectly involved with MSM and their sexual health. These strategies
practiced by PHE ensure that MSM are supported with services that are
welcoming and are for their needs. Long time has gone by when sex
between two consenting adult men used to be considered criminalised in
the United Kingdom. The legislation was created in 1967 to protect the
rights of lesbian, gay, bisexual and transgender (LGBT). According to
PHE, MSM has received improvement in the acceptance in the society.
PHE explains that in 1991 only 22% men and 28% women believed that
sex between men was not wrong at all whereas this number went up to
48% and 66% among men and women in the year 2010 DOH 2014a.
These figures clearly illustrates that PHE is working hard to reduce the
inequalities faced by MSM in the society.

Despite these high improvements with regard to being accepted in the

society, MSM continue to experience inequalities related to sexual
health. According to Public Health England there is one in 20 MSM in
the UK are living with HIV infection. Therefore, PHE approaches on
improving the sexual health of MSM using a holistic approach, where
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they tackle the health and wellbeing of MSM from early childhood,
through adulthood and into their senior years (the Life Approach).
Through this approach PHE aims to reduce HIV infections among MSM
by 50% from 3,000 in 2012 to 1,500 in 2020. PHE works with Home
Office to accomplish the set goals. After the Equality Act in 2010, the
Government has worked to increase the visibility of the needs of lesbian,
gay and bisexual individuals which also includes MSM populations.
Life Course Approach makes recommendations for public on sexual
health. It talks about health is not just the individual behaviour but it is
also made by the environment where people interact with homes,
families, work, communities, schools and faith organisation, Therefore,
it is very important for MSM to feel accepted and supported by family
and friends.

Besides the above mentioned strategies from different governmental

sectors to make public aware about the MSM group and to reduce STIs
and HIV among the group, The UK national guidelines for HIV testing
(2008) make call for higher levels of HIV testing outside the non-HIV
specialist setting as a way to reduce the stigma associated with HIV
infection. Also, the policy from WHO on HIV testing is another way to
reduce the occurrence of stigma associated with HIV among MSM. The
policy explains that each testing of individuals on HIV and STIs must be
confidential, be accompanied by counselling and can only be conducted
with informed consent. By maintaining all these standards from these
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national and international sectors, stigma, discrimination, judgmental

approach to this minority group can be reduced in the society.

So many efforts must have been applied for these strategies and policies
to have been written down. There seem to be more than enough policies
from WHO, DOH and PHE to reduce the rate of HIV and STIs among
MSM. Despite all these policies, there still is a high rate of STIs and
HIV among the group. Therefore, the policies are already there, now is
the time to act upon these policies in a day to day life. For example, the
strategy called integrated sexual health model from DOH is one of the
easiest strategies for public to know about HIV and STIs. This model is
for all the population not just for MSM group. There is emphasis given
to those who are first time service users and those that remain at risk.
The strength of this model is that this model is based on evidence based
and it includes the overall population. The extended hours of service
provided by health professionals to the public on this model is another
strong point to be noted on this model.

Emphasis should be given to the proper implication of integrated sexual

health model generated by DOH to reduce the occurrence of STIs and
HIV among MSM in the UK. The one stop shop is a great tool of
which public might not be aware of. Through the help of media, the
governmental sector should educate the public about this model and one
stop shop. Public should be educated to access this tool to ask questions
related to sexual health to the professionals. By using this model people
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would be able to access the service from the comfort of their homes.
They do not have to fear about being judged, discriminated as there is no
face to face interactions. This is very confidential and public can ask any
questions regarding different sexual orientation, STIs and HIV.

The recommendation by PHE to decrease the inequalities among MSM

is another strong strategy to reduce the incident of HIV and STIs among
MSM. PHE believes that when everyone is treated equal in a society
people do not feel discriminated. In a society where everyone is equal, it
is easy to instruct to make healthy choices. PHE not only works to
educate the public about HIV and STIS but it also ensures that the
educational facilities and the health workers are knowledgeable and well
trained on the subject. PHE believes in making sure that the health
professionals are welcoming and working hard to meet the set goals to
reduce the number of STIs and among HIV. Furthermore, the policy
from PHE to protect the rights of LGBT is a huge step to treat this group
equally.

Another strategy from PHE for MSM using a holistic approach is one of
the strategies which include everyone from early childhood, through
adulthood and into their senior years. This strategy is one of the best
among all the strategies mentioned in this essay because it works on the
holistic approach for MSM. Through this strategy, the public become
aware of MSM group and their orientation since the early childhood.
The challenge that the governmental body has to face when applying this
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strategy is to provide sufficient professional health workers to work with

different age groups of population. The strategy mentioned by the UK
national guidelines for HIV testing 2008, which makes call for HIV
testing outside the non-HIV specialist setting helps in reducing the
stigma and discrimination associated with HIV infection. Furthermore,
the policy from WHO on making each testing confidential and only with
informed consent respects the human rights of public.

Besides all these strength of the strategies that come from different
governmental sectors, different approach of teaching should be
conducted based on different groups of MSM. Men in each groups need
to be informed about risks of HIV and STI, and they are to be supported
to make decisions about reducing their risks. For example, according to
PHE (2013) younger men who are less than 26 years old need different
approach as this group is very sexually active with multiple partners and
also they are engaged in condomless anal sex behaviour. On top of all
this, this particular group of population appears to be less knowledgeable
about the risks. Therefore, they need to be included in a learning group
about anal sex before they are engaged in sexual behaviour. The concept
of Health Belief model can be applied in educating the public about
HIV and STIs. This model explains about how change can be brought
about. By making public knowledgeable about HIV and STIs there will
be willingness to change and that through exploring the things that
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hinder or encourage changes in peer groups people will feel supported

in their capacity to make changes.

MSM in the UK are at increased risk of acquiring STIs than the other
heterosexual groups UK National guidelines for HIV testing (2008). A
report prepared by British Association of Sexual Health and HIV and
British infection society says despite the stigma associated with HIV, the
rate of infection can be reduced by applying the principle of
confidentiality. The result of STIs and HIV infections should be given
directly by the testing clinician team to the patient. Consent must be
obtained by the medical team. Providing written confirmation of the
result to the patients and notifying the partner/partners to reduce the
incident of transmission play a vital role.

There are some difficulties that are faced by the counsellor when
dealing with MSM with HIV and STIs. Therefore, the counsellor must
be helpful to clients to cope with positive result and to make difficult
decisions regarding disclosure, treatments and risky behavior.
Sometimes the counsellor is the only person they can talk to. They
should therefore be very non-judgmental to the groups of MSM who
come to the clinics. They should establish an informed consent and be
professional to work on the confidentiality.

Finally, the approach of educating our younger generations needs to be

changed. PHE says, with foundation of clear, accurate and related
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information at an early age, public will be well educated on a good

sexual health. Therefore, school plays a vital role in providing the
knowledge and skills for younger generation on sexual identity. Through
this new approach of education, younger generation will be well
informed about biological or physical aspects of same-sex relationships.
This would help in reducing the occurrence of discrimination and stigma
to MSM groups as people have clear understanding about different
sexual orientation of different individual. Everyone will be treated
equally and MSM do not have to fear about opening up about their
sexual orientation or about STIs and HIV. Therefore, it is clear from
this essay that being educated and applying the knowledge is a vital to
reduce the occurrence of STIs and HIV among MSM.

References
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Bonell, C., Hickson, F., Reid, D., and Weatherburn, P. (2010) Illicit drug
use among men who have sex with men in England and Wales.
Addiction Research and Theory, 18(1), p. 14-22 Academic search Elite,
EBSCOhost. [Accessed: 01 December 2014].

Dowson, L., Fisher, M., Kobler, Cober, C., Perry, N., and Richardson,
D. (2012) Why some MSM present late for HIV testing. A Qualitative
Analysis, AIDS Care, 24(3), p. 204-209 Academic search Elite,
EBSCOhost. [Accessed: 01 December 2014].

Medical Foundation for HIV and Sexual Health (MEDFASH). (2013)

Promoting excellence in HIV and sexual healthcare. [Online]. Available
at: www.medfash.org.uk/. [Accessed: 30 November 2014].

National Aids Trust (NAT). (2014) Men who have sex with men.
[Online]. Available at: http://www.nat.org.uk/HIV-Facts/Statistics/.
[Accessed: 30 November 2014].

Public Health England (2014) HIV and STIs in men who have sex with
men in London. [Online]. Available at:
https://www.gov.uk/government/. [Accessed: 04 December 2014].

Public Health England (2014) HIV in the United Kingdom. [Online].

Available at: https://www.gov.uk/government/statistics/hiv-in-the-
united-kingdom. [Accessed: 04 December 2014].
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Public Health England (2013). HIV Prevention Needs Assessment for

London. [Online]. Available at: http://www.londoncouncils.gov.uk/.
[Accessed: 30 November 2014].

Public Health England (2014) Promoting the health and wellbeing of

gay, bisexual and other men who have sex with men. [Online]. Available
at: https://www.gov.uk/government/uploads/.../MSM_document.pdf.
[Accessed: 30 November 2014].

Public Health England (2014) Strategic framework to promote the health

of gay, bisexual and other men who have sex with men. [Online].
Available at: https://www.gov.uk/strategic-framework-to-improve-the-
health-and- wellbeing-of-gay-bisexual-and-other-men-who-have-sex-
with-men/. [Accessed: 30 November 2014].

UK National Guidelines for HIV Testing (2008). [Online]. Available at:

http://www.bhiva.org/documents/guidelines/testing/. [Accessed: 04
December 2014].

World Health Organisation (2014) HIV testing and counselling.

[Online]. Available at: http://www.who.int.hiv/topics/vct/en/index.html.
[Accessed: 30 November 2014].
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